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Health IT

ACOs Struggle to Achieve Interoperability

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Efforts by accountable care organizations to improve communications shows the difficulty providers face in meeting federal interoperability goals

The seamless sharing of information across the U.S. healthcare system is the ultimate aspiration of the federally mandated modernization of health IT. But achieving “interoperability” – a quest that has been compared to the search for the Holy Grail – will be no small task.

Accountable care organizations (ACOs), which enable healthcare providers to cooperate with each other in order to deliver more effective care, provide an indication of the challenges in achieving interoperability at a broader level.

While ACOs are all about collaboration, the IT system that is supposed to link ACO providers has been all about exclusivity.

To improve care and deliver savings, ACOs, bring together normally competing providers – including primary care physicians, specialists, surgery centers, some health agencies, nursing homes and rehabilitation centers.

For ACOs to function well, the electronic health record (EHR) systems of different providers will have to communicate with each other, but this is not the case today, says Bill Beighe, the chief information officer at Physicians Medical Group of Santa Cruz County, an independent physician organization that is participating in a commercial ACO with Blue Shield of California.

“Most EHR vendors give lip service to data exchange and make interoperability at any level expensive and difficult to achieve,” Beighe told HealthBiz Decoded. The systems are “nothing more than electronic silos of data,” he said.

Beighe and other CIOs have been on a quest for EHR interoperability since before ACOs were envisioned. There have been a lot of small steps, he says, but the ultimate goal – exchanging data machine-to-machine, without human intervention – is still a long way off.

To attain true interoperability, EHR vendors would have to agree to the same data standards, but they are too competitive to do so, said Beighe. So ACOs and other providers that want to share data have made end-runs around the systems. For example, they can use interoperability software that translates the different languages of EHR systems for specific functions. But in many cases, providers still have to enter data by hand, which is time-consuming.

ACOs Hasten Need for Interoperability 

The advent of the ACO is changing the landscape of health IT, says William Spooner, senior vice president and chief information officer at Sharp HealthCare, a health system in San Diego that recently started a Medicare Pioneer ACO.

Before ACOs, each healthcare system would basically use its own EHR system for its own patients. But “in an ACO world, patients can go anywhere they want,” said Spooner. “That means that ultimately, you need to have some kind of interoperability with every provider in the area.”

To link different EHR systems, Sharp is using interoperability software from dbMotion, a Pittsburgh-based company that establishes a common language for different EHR systems. Customizing the connections requires a great deal of work, but the resultant flow of data is well worth it, says Spooner.

In addition to providers sharing patient data, Sharp’s ACO can analyze care patterns across all providers, track efficiency and report 65 quality metrics required by the federal government. That means “the analytics are extremely important for an ACO,” he said.

For providers who have not shifted to an EHR, the ACO may decide to help them buy an EHR system. But in the meantime, these providers need to send and receive unstructured data across the ACO. They can do this by using a secure Web portal, called a health information exchange (HIE). In addition to the Sharp HIE, a new regional exchange for the San Diego area, funded by the federal government, will help these providers plug into the Sharp ACO and other networks as well.

Future Promise from Mandate

Many observers think the slow pace toward interoperability may speed up in the near future, due to the growth of ACOs, the rise of HIEs, and demands of federal “Meaningful Use” incentive payments for healthcare IT.

The country’s top health IT official Dr. Farzad Mostashari, who is charged with distributing $27 billion to incentivize providers to adopt EHRs, said practices that thrive will be the ones that can manage information flows not just within the practice, but with other parts of the healthcare system.

“Usability and interoperability – the ability of the system to talk, are two things I tell providers they should really be watching out for,” Mostashari, the National Coordinator for Health Information Technology, said in a recent interview.

Fueled by the federal subsidies, state and regional HIEs are sprouting up across the country, and most of them are using a new method of data transmission called Direct messaging. Direct can be used to send unstructured data, such as a patient’s chart. Or it can transmit more structured data, such as the continuity of care document (CCD), which can be inputted directly into EHR systems.

The Meaningful Use program is pushing EHR vendors to accept the CCD, an electronic document exchange standard for sharing summary information for the patient’s record. To qualify for Stage 1 of Meaningful Use, EHRs have to transmit certain elements of the patient record through a CCD.

“Unfortunately, Stage 1 set a very low bar on the required elements,” Beighe said. While the data fields included allergies, a medication list and diagnostic test results, they did not include other necessary fields – such as history of present illness, progress note, reason for referral and operative report.

These fields, however, will be included in Stage 2 of Meaningful Use, which will begin to take effect later this year. New EHR systems that will be out this fall are expected to include the fuller version of the CCD, making the CCD more useful and bringing ACOs a step closer to true interoperability, to Gary Zegiestowsky, chief executive of Informatics Corporation of America, an interoperability company based in Nashville.

Meanwhile, EHR vendors are showing more interest in harmonizing their products with each other. In early March, a number of leading EHR vendors announced they would work together to improve interoperability. The new CommonWell Health Alliance includes Cerner, McKesson, Allscripts, Athenahealth and Greenway Medical Technologies.

Zegiestowsky thinks that the gradual changes in healthcare will make it easier for ACOs to function. “Technology can be a supreme enabler for managing your population, but it’s a step-by-step process,” he said. “You build out capability to make it more usable and actionable.”

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